Social Media: Examination of Renal Professional Practices and Guiding Principles

Lisa Hall, MSSW, LICSW, Northwest Renal Network

The widespread use of technology and social networking websites, such as Facebook and Twitter, creates new avenues for renal professionals to share information. However, intentional or unintentional virtual contacts with patients and potential breaches of professional ethics are always possible. During a session at the NKF 2012 Spring Clinical Meetings in Washington, D.C., attendees discussed ethical dilemmas in this era of rapidly expanding social media, were polled regarding their practices, and expressed the need for further examination of the implications of new technologies for renal patients, professionals, and organizations. By seeking consultation with regard to ethics and reviewing professional, regulatory, and agency policies, health care professionals can stay on the safe side of social media.

INtROdUCtION With limited control of who reads or follows social net- A recent post on the Council of Nephrology Social Workers working content, intentional and unintentional virtual professional email LISTSERV inquired about how social contacts between staff and patients are always possi- workers handle “Friend” requests on Facebook from ble. Some of the situations that may arise with new patients. This prompted a lively discussion of professional technology: emails between staff and patients; patients boundaries, dual relationships, and the need for further “Googling” (using the Google online search engine) staff; exploration of ethical practices and policies around this staff “Googling” patients; and issues of confidentiality and ever-changing social landscape (NKF CNSW LISTSERV, privacy. Information provided could be inadvertently used 2011). The purpose of this article is to examine the many to identify a patient. The ease of posting and the common- challenges faced by social workers related to social net- place nature of sharing information via social media may working, and to discuss some guiding principles. appear to blur the line between one’s personal and professional life. What is social media? Social media is the use of web-based technology that allows the exchange of user-generated Advantages of Social Media content. Facebook, the ubiquitous social networking util- There are numerous advantages to having social networking ity, presently has 1 billion users (Facebook, 2012). Twitter accounts. Information can be disseminated quickly and to a claims 140 million users (Bennett, 2012; Wasserman, 2012). large population at no cost. Social media is used for: The majority of national renal professional organizations, patient organizations, and dialysis corporations now utilize • A venue for online discussion of health-related topics Facebook and Twitter. and trends Facebook is a social networking service which requires • A bulletin board for posting upcoming events users to register before using the site, after which they may • Fostering professional connections create a personal profile, list other users as friends, and • Marketing exchange messages, including automatic notifications when they update their profile. For those who are unfamiliar with • Sending, receiving, and accepting social invitations Twitter, it is a microblogging service that allows users to • Sharing local, national, and international news send messages of up to 140 characters (“Tweets”) to recipi- • Forging ties with out-of-state family and friends ents known as “followers.” While on Facebook, both parties must agree to be friends; with Twitter, users have limited • Exercising humor and creativity control of who follows them. “Tweets” may be read by any- • Sharing and receiving information relevant to lives one, whether registered with Twitter or not. and interests Blogs are online journals written by one person or a group • Keeping up with professional trends and contacts of contributors, often focused on a specific field or specialty. Blogs permit writers to engage in conversations with read- • Participation in civic action, including advocacy and ers. There are many nephrology-related blogs, websites, public policy and LISTSERVs: patient-authored, physician-authored, and Renal Business Today (2010) featured the article “Social university-based. The term “LISTSERV” has been used to Media in Nephrology.” The director of communications for refer to electronic mailing list software applications, allow- DaVita provided comments in this article on social media: ing a sender to send one email to the list, which transpar- “This platform benefits doctors, caregivers, patients, and ently sends the email to all addresses subscribed to the list. their loved ones in several ways: patients can share experiences and benefit from industry information to improve

Corresponding author: Lisa Hall, MSSW, LICSW, Northwest Renal Network, 4702 42nd Ave SW, Seattle, WA 98116; [email protected]; 206.923.0714, ext. 109. 32 Social Media their quality of life, loved ones can share experiences and • What happens when your patient discovers you have learn how they can offer better support, and the doctors/care 20 Facebook Friends in common? Will they wonder team members can learn first-hand what their patients are what you are sharing with these friends? looking for, giving them prime ways they can better their facilities—especially on a human level.” Dual relationships—The NASW Code of Ethics (NASW, 1996) stipulates that social workers should not engage in Risks Related to Social Networking dual or multiple relationships, with clients or former clients, in which there is a risk of exploitation or potential harm To understand the limits of appropriate use of social media, to the client. Accepting an invitation from a client to be a it is important to have an understanding of the risks faced by friend on Facebook (or other social network sites) creates a professionals. The National Association of Social Workers dual relationship. (NASW, 2005) and Association of Social Work Boards (ASWB) have developed the Standards for Technology and Effect on team-based patient care—Cyber-bullying, or the Social Work Practice to create a uniform document for the use of cell phones or other devices to send or post text or profession. The specific goals of the standards are: images intended to hurt or embarrass another person, is detrimental to a cohesive health care delivery team. For • to maintain and improve the quality of technology- example, a member of the interdisciplinary care team send- related services provided by social workers; ing “Tweets” about patients that are unprofessional in nature • to serve as a guide to social workers incorporating can result in a loss of therapeutic effectiveness, loss of technology into their services; objectivity, and exploitation. • to help social workers monitor and evaluate the ways Legal risks—What you learn about patients in social media technology is used in their services; and could become a legal issue. What if a patient were to tweet • to inform clients, government regulatory bodies, about being suicidal? Could you be professionally liable for insurance carriers, and others about the professional failing to prevent harm? standards for the use of technology in the provision NKF SCM12 “Social Media and Boundaries” of social work services. Session—Audience Response Results The discussion of risks below, based on that guide, is not Using audience response system technology, attendees at the meant to be exhaustive or to reflect the order of importance. NKF 2012 Spring Clinical Meetings session on May 12 in Washington, D.C. (Hall, 2012), were polled regarding their Confidentiality—Information that is shared with staff by personal and professional use of social media. Respondents patients, including patients’ identities, must remain confi- were a fairly even spread across ages, ranging from 20 to dential unless the patient authorizes release. This require- 70, with a few more attendees in their 20s (18 attendees, or ment could easily be violated through use of a website 30%). Ninety percent were social workers, 5% nurses, and designed for social networking. Users run the risk of violat- 5% were other renal professionals. Of those surveyed more ing patients’ privacy and confidentiality by disclosing too than 45% stated they used social media on a daily basis, and much information. Emails, LISTSERVs, social networking only 27% stated they never used social media. Interestingly, websites, tweets, and blogs are not private, and can easily the sample’s use of social networks highlighted the many be shared by the recipient with others. Even content that gray areas faced by renal professionals. Eleven percent has been deleted is accessible. Some examples of potential reported receiving a “Friend request” from patients, with privacy and confidentiality violations: 7% reporting they accepted the request. Thirteen percent • There is always the risk of disclosing too much thought it was acceptable to engage patients on social net- identifiable information. A mistaken belief is that works, depending on the situation, while 22% were uncer- it is acceptable to discuss or refer to patients if they tain what to do if a previous patient tried to “Friend” them are not identified by name, but referred to by a after treatment had been completed. nickname, room number, diagnosis, or condition. There are many doctors and facilities beginning to use social • If we “accept” a patient’s “Friend request” (for networking to expand their practices, utilizing platforms like instance on Facebook or LinkedIn), there is risk of Facebook, Twitter, and others as marketing tools. Common possible exposure of the patient’s identity to others. in these approaches is the use of patient testimonials, or In order to make a “Friend” on Facebook, a user asking patients to rate doctors on places like Angie’s List or sends a “Friend request” to another user. If that user Yelp. When asked what to do when a renal patient “Likes” confirms that they are indeed friends, then the users a Facebook page that is professionally oriented, attendee appear on each other’s Friend lists and they can send responses were split pretty evenly between choices (i.e., each other messages, write on each other’s “walls” this is a breach of confidentiality; this is acceptable; and or pages, or chat. The identity and number of friends uncertain whether this is appropriate). The “Like” button is is displayed conspicuously, and is easily noticeable a Facebook feature where users can “Like” content such as by anyone who looks at a person's Facebook page. Social Media 33 status updates, comments, photos, links shared by friends, Current Events as well as advertisements, articles, and other online content. A survey of the Boards of Nursing conducted by National One hypothetical situation that was posed to attendees: Council on State Boards of Nursing (NCSBN, 2010) indi- “You are friends with coworkers on Facebook. One posted cated an overwhelming majority, 33 of 46 respondents, photos of his birthday party, revealing that patients and other reported receiving complaints about nurses who have vio- colleagues attended. Should you bring this to your clinical lated patient privacy by posting photos or information about manager’s attention?” Seventy-six percent responded yes, patients on social networking sites. Disciplinary actions while the others either would not report the incident (13%) were taken based on these complaints, including censure, or were uncertain (11%). Some who responded “yes” com- letters of concern, conditions placed on the nurse’s license, mented that this seems like a pretty clear violation of bound- and licensure suspension. aries, and they were surprised by the “no” and “uncertain” One recent incident was publicized in the media (Stokowski, responses. 2011). Four students were dismissed from their nursing Another scenario inquired whether it is ethical to bring up program after a student posted a photo on Facebook show- questionable Facebook content with a patient. For instance, ing her posing, smiling widely, over a placenta in a plastic a woman three months pregnant posts a photo of herself tray, while holding up the umbilical cord in her gloved hand. with a cigarette in one hand and a beer in the other. Renal Although nothing in the photograph identified the patient professionals were split on whether to confront the woman, from whom the placenta was taken, the student was wearing though National Association of Social Workers Code of a uniform with a visible decal, as well as a hospital badge on Ethics (NASW, 1996) state that social workers should a lanyard that contained identifying information. Although respect clients’ right to privacy, and should not solicit the photo was taken down from her Facebook page, it is still private information from clients unless it is essential to available on the internet, as it was picked up by the press and providing services. The fact that information about patients a host of online bloggers. is available electronically through various search engines In a recent research letter to the Journal of the American does not mean we should access it. Seeking information on Medical Association (Hensley, 2012), it was reported that the internet about a patient without his/her knowledge may 3% of “Tweets” from self-reported physicians on Twitter violate an implied contract and erode the patient’s sense were unprofessional. The letter shared results of a nation- of trust. Attendees debated whether a Facebook posting is wide survey of state medical boards, the majority of whom indeed “private” and, in the case of the hypothetical preg- have received reports of doctors behaving badly online. nant woman, expressed concern about the rights of the fetus. The most common violations reported were: inappropriate Attendees were also asked to consider the following ques- patient communication online, e.g., sexual misconduct; use tion regarding a posting on a professional LISTSERV: “You of Internet for inappropriate practice, e.g., prescribing with- post on the LISTSERV a dilemma you are facing with a out established clinical relationship; and online misrepre- particular patient at your facility. Your LISTSERV signa- sentation of credentials. Most often, the boards have learned ture lists your facility address and affiliation. Is this patient about the problem from patients or their families. Fifty-six potentially recognizable to LISTSERV members?” Eight- percent of the boards had restricted or suspended licenses, two percent responded “yes,” 9% responded “no,” and 9% and have revoked at least one doctor’s license at some point were “uncertain.” Attendees commented that examination for bad behavior online (Greyson, Chretien, Kind, Young, of this issue created new awareness of the importance of & Gross, 2012). guarding individual identifying information when corre- Results of a survey of medical school administrators sponding by email. (Chreitien, Greyson, Chretien, & Kind, 2009) found a fair It was clear from the audience discussion that, when exam- amount of unseemly conduct by their students, including ining social platforms, gray areas exist. For instance, profes- violations of patient confidentiality, student use of profanity, sionals who live and practice in small towns or rural settings frankly discriminatory language, depiction of intoxication, have difficulty avoiding dual relationships. Additionally, and sexually suggestive material. Among the 78 medical professionals who serve on boards with patients may have schools that responded to the survey, 60% reported inci- difficulty avoiding shared LISTSERVs, blogs, or social dents of students posting unprofessional content on the web. networking sites. Unprofessional online content posted by medical students Interestingly, though renal professionals face ethical dilem- has resulted in disciplinary action by medical schools, mas related to appropriate use of social media, only 47% of including dismissal in some cases. those surveyed said they were certain that social networking Amednews.com reported in April (Dolan, 2012) that policies were addressed at their facilities or practices. patients increasingly want social media to be something that There were less than 100 respondents in the audience. It helps them coordinate care and navigate the health system, would be interesting to repeat this polling with a larger and and they think physicians are the best people to deliver it. more randomized sample, which would provide the oppor- Health care organizations are reshaping their social media tunity to explore some cross-tabulations. strategies to engage patients, interact with them, and even 34 Social Media provide services in an attempt to help bring down the costs Some Recommendations of providing care. Examples include scheduling appoint- If you are uncertain, seek consultation on ethical issues. ments, sending reminders, and making referrals to special- Some of the professional values and personal guidelines to ists. Mercy, a 28-hospital system in the Midwest, is creating keep in mind when using social media: an application to allow patients to “share” their physicians’ profiles with Facebook Friends. • Conflicts of interest—Avoid activities that interfere with the exercise of professional discretion and Ethical Considerations impartial judgment. When posting on professional When using technology in its various forms, renal pro- websites or commenting on a blog, keep it profes- fessionals need to adhere to ethical, legal, and regu- sional, as your comments can be viewed by the pub- latory standards. The Health Insurance Portability and lic and are archived. Accountability Act (HIPPA) (U.S. Department of Health • Professional boundaries—“Friend requests” from & Human Services, 1996) defines individually identifiable patients should be respectfully declined just like any information, and establishes how the information may be other kind of social invitation from a patient. used, by whom, and under what circumstances. Individually • Privacy and confidentiality—Be wary of providing identifiable information is any information that relates to enough information that could be used to identify a the past, present, or future physical or mental health of an patient. individual, or that provides enough information that leads someone to believe the information could be used to identify • Do no harm—Overexposure on social network- an individual. ing sites may confuse patients and have negative repercussions for patient-staff relationships. Manage In addition to adherence to HIPAA privacy regulations, it is information available about you online. Use the important to review your individual professional organiza- highest privacy settings for social networking sites. tion’s policies on ethical practices in the use of technology. Create a “lock” on Twitter accounts in order to deny Several professional organizations have updated their poli- access to requests to follow you. Twitter provides cies to address social media. Those that are relevant to renal the option to "lock" or protect your account, which professional practice are summarized in Figure 1. means that you must approve people before they Possible Consequences of Violations can “follow” you and only your “followers” can view your “tweets.” Keep in mind that inappropriate disclosures or postings on • Dignity and respect toward colleagues—Ask your- social media may result in disciplinary actions by profes- self before posting whether the content will be sional boards, state and federal entities, and employers. detrimental to your employer or impair working Additionally, individual lawsuits can be filed against pro- relationships. fessionals and subject employers to lawsuits or regulatory consequences (e.g., defamation, invasion of privacy, or SUmmARY harassment). The reputations of health care organizations are at stake. Renal professionals should not shy away from using social media. In fact, social media are more likely to play an Professional boards may investigate reports of inappropriate increasing role in health care. With thoughtful examina- disclosures on social media on the grounds of: unprofes- tion of professional guidelines, creation of agency policies sional conduct, unethical conduct, moral turpitude, misman- regarding ethics in the use of new media by staff, and dis- agement of patient records, revealing privileged communi- cussions with patients regarding policies and procedures, cations, and breach of confidentiality. Consequences may we will be able to participate in the social media revolution include reprimand or sanction, assessment of monetary fine, without fear of doing harm. and temporary or permanent loss of licensure. State and federal entities oversee violation of laws established to protect privacy, confidentiality, and prevention of patient abuse or exploitation. Consequences may include civil and criminal penalties, fines, jail time, and personal liability. Social Media 35

Figure 1. Professional Organization Policies and Principles

NASW and ASWB Standards for Technology and Social Work Practice (National Association of Social Workers, 2005) • Adhere to ethical, legal, and regulatory standards (privacy, confidentiality, client records, informed consent) • Inform clients when real or potential conflicts of interest arise; take steps to resolve; clients’ interests are primary • Do not engage in dual or multiple relationships with clients or former clients in which there is risk of exploitation or potential harm • Respect clients’ right to privacy; do not solicit private information unless it is essential for providing services • Do not permit private conduct to interfere with the ability to fulfill professional responsibilities • Overexposure on social networking sites may confuse clients and may negatively impact the relationship (personal internet postings are a form of self-disclosure)

ANA’s Principles for Social Networking and the Nurse: Guidance for the Registered Nurse (American Nurses Association, 2011) • Negative aspects of social networking sites include: loss of privacy, legal liability, and loss of professionalism • Crossing personal and professional boundaries can represent conflicts of interest for the nurse • Protect the integrity of self and profession • Maintain patient privacy and confidentiality; treat patients with dignity and respect • Promptly report breaches of confidentiality or privacy • Do not make disparaging remarks about employers or coworkers

NCSNB White Paper: A Nurse’s Guide to the Use of Social Media (National Council of State Boards of Nursing, 2011) • Avoid inadvertently disclosing confidential or private information about patients (including use of patient information or likeness) • Maintain professional boundaries online • Do not disparage employers or coworkers • Be aware of employer social media policies • Report any breaches to your state’s Board of Nursing (BON)

AMA Policy: Professionalism in the Use of Social Media (American Medical Association, 2012) • Policy does not explicitly recommend against “Friending” patients • When interacting online, maintain appropriate boundaries of patient-physician relationship, just as with any other context • Recommend separating personal and professional content online

ACP Ethics Manual, 6th Edition—A Comprehensive Medical Ethics Resource (American College of Physicians, 2012; Barclay, 2012) • Physicians who use social media should not blur social and professional boundaries • Policy provides guidance regarding confidentiality in electronic health records

Academy of Nutrition and Dietetics (2011) • Development of an ethics opinion is underway, based on the following guiding principles: o Do not engage in false or misleading practices or communications o Protect confidential information o Provide full disclosure about limitations on ability to guarantee full confidentiality o Be alert to real or potential conflicts of interest and act when conflict arises 36 Social Media

REFERENCES National Association of Social Workers (NASW). (2005). Academy of Nutrition and Dietetics. (2011). Call for NASW and ASWB standards for technology and authors and reviewers: New ethics opinion social social work practice. Retrieved May 30, 2012, from media. Retrieved May 30, 2012, from http://www. http://www.socialworkers.org/practice/standards/ eatright.org NASWTechnologyStandards.pdf American College of Physicians. (2012). ACP ethics man- National Council of State Boards of Nursing (NCSBN). ual, 6th edition—A comprehensive medical ethics (2010). Summary of social networking survey to boards resource [Electronic version]. Retrieved May 30, 2012, of nursing. Retrieved August 2012, from https://www. from http://www.acponline.org/running_practice/ ncsbn.org/2632.htm ethics/manual/ National Council of State Boards of Nursing (NCSBN). American Medical Association. (2012). AMA policy: (2011, August). White paper: A nurse’s guide to the use Professionalism in the use of social media. Presented of social media. Retrieved May 30, 2012, from https:// at the 2012 Interim Meeting. Retrieved May 30, 2012, www.ncsbn.org/11_NCSBN_Nurses_Guide_Social_ from http://www.ama-assn.org/ama/pub/meeting/ Media.pdf professionalism-social-media.shtml National Kidney Foundation Council of Nephrology Social American Nurses Association. (2011). ANA’s principles Workers. (2011, March 29). Message posted to CNSW for social networking and the nurse: Guidance for the LISTSERV at http://www.kidney.org/professionals/ registered nurse [eBook]. Retrieved August 2012, from cnsw/listserv.cfm http://www.nursesbooks.org/Main-Menu/eBooks/ Renal Business Today. (2010, June 9). Social media in Principles/Social-Networking.aspx nephrology: Hype or help? Renal Business Today. Barclay, L. (2012). Release of updated American College of Retrieved June 9, 2010, from http://www.renal- Physicians ethics manual CME. Medscape Education. business.com/articles/2010/06/social-media-in- doi: http://www.medscape.org nephrology-hype-or-help.aspx Bennett, S. (2012, October 29). Twitter on track for 500 Stokowski, L. (2011). Social media and nurses: Promising million total users by March, 250 million active users or perilous? Medscape Online. doi: http://www. by end of 2012. Retrieved October 20, 2012, at http:// medscape.com/viewarticle/753317 www.mediabistro.com/alltwitter/twitter-active- U.S. Department of Health & Human Services. (1996). total-users_b17655 Health Insurance Portability and Accountability Act Chretien, K. C., Greysen, S. R., Chretien, J. P., & Kind, T. (HIPAA). Retrieved August 2012, from http://www. (2009). Online posting of unprofessional content by hhs.gov/ocr/privacy/ medical students. Journal of the American Medical Wasserman, T. (2012, March 21). Twitter says it has Association, 302, 1309–1315. 140 million users. Mashable Social Media. Dolan, P. (2012). Patients want to use social media tools Retrieved November 6, 2012, from http://mashable. to manage health care [Editorial]. American Medical com/2012/03/21/twitter-has-140-million-users/ Association News. Message posted to http://www. ama-assn.org/amednews Facebook. (2012, October). Key facts. Retrieved November 6, 2012, from http://newsroom.fb.com/Key-Facts Greyson, S., Chretien, K., Kind, T., Young, A., & Gross, C. (2012). Physician violations of online professionalism and disciplinary actions: A national survey of state medical boards. Journal of the American Medical Association, 307(11), 1141–1142. Hall, L. (2012, May 12). Social networking and boundaries: Where to draw the line? Presented at the NKF 2012 Spring Clinical Meetings, Washington, D.C. Hensley, S. (2012). Doctors’ missteps online can lead to disciplinary action [Blog]. Message posted to http:// www.npr.org National Association of Social Workers (NASW). (1996). Code of ethics. Retrieved August 2012, from http:// www.socialworkers.org/pubs/code/default.asp